ODJFS PRESCRIPTION MEDICATION AUTHORIZATION FORM

Student's Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Special Health Condition
Does the condition require medication
What are the signs, symptoms, or situations which require staff to take action?
None. The patient has ADHD
What are the training instructions for the procedures staff have to follow? (include all steps to care for the child/perform the medical procedure)
Locked storage of the medication
What are the activities, foods, environmental conditions, etc. to avoid?
Medication #1
Medication #1 Dosage
Time of Admin Medication #1
Ending Date of Admin Medication #1

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
(I need to add more medications to the form)
Medication #2
Medication #2 Dosage
Time of Admin Medication #2
Ending Date of Admin Medication #2

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Medication #3
Medication #3 Dosage
Time of Admin Medication #3
Ending Date of Admin Medication #3

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
What are the training instructions for the procedures staff have to follow? (include all steps to care for the child/perform the medical procedure)
Not applicable. The medication(s) should be given daily
What are the actions to be taken if symptoms do not subside?
Not applicable.
Physician/Provider Name
Date of physician signature

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: